Recruitment
Junior club membership form
BLACKWELL MINERS WELFARE FOOTBALL CLUB
We are very pleased to welcome you to Blackwell Miners Welfare Football Club
To ensure that we have the correct contact details for you, please insert the information requested below and return this form to The Club Secretary. If you are under 16 please also ask your parents or guardian to sign this form before it is returned.
We will also use this information to ensure that you are kept informed about club events.
Personal details
Name:
Address:
Postcode:
Home telephone number:
Mobile: email:
Date of birth: Gender: Male ¨ Female ¨
Sports equity monitoring
Whilst it is not compulsory that this section is completed the following paragraph explains why it is important.
Sport can and does play a major role in promoting the inclusion of all groups in society. However, inequalities have traditionally existed within sport, particularly in relation to gender, race and disability. Sport England is committed to promoting and developing sports equity, which is about fairness in sport, equality of access, recognising inequalities and taking steps to address them. By monitoring the profile of young people in sports clubs, national governing bodies of sport and Sport England can identify any issues relating to under-representation of different groups and can together develop strategies to ensure that all young people have the opportunity in the future to develop and progress in sport.
Ethnicity
In order to help the club monitor its membership can you please tick one of the following boxes to identify your ethnic group / origin:
Choose one section from A to E and then tick the appropriate box.
AWhite
0 British 0 Irish
0 Any other white background (please specify):
BMixed
0 White & Black Caribbean0 White & Black African
0 White & Asian
0 Any other mixed background (please specify):
CAsian or Asian British
0 Indian0 Pakistani0 Bangladeshi
0 Any other Asian background (please specify):
DBlack or Black British
0 Caribbean0 African
0 Any other Black background (please specify):
E Chinese or other ethnic group
0 Chinese
0 Any other (please specify):
Disability
The Disability Discrimination Act 1995 defines a disabled person as anyone with ‘a physical or mental impairment, which has a substantial and long-term adverse effect on his or her ability to carry out normal day-to-day activities’.
Do you consider yourself to have a disability? 0 Yes 0 No
If yes, what is the nature of your disability?
0 Visual impairment
0 Hearing impairment
0 Physical disability
0 Learning disability
0 Multiple disability
0 Other(please specify):
Sporting information
Have you played FOOTBALL before?0 Yes 0 No
If yes, where have you played the sport: (please indicate below)
0 Primary school
0 Secondary school
0 Local authority coaching session (s)
0 Club
0 County
0 Other (please specify):
Medical information
Please detail below any important medical information that our coaches/junior coordinator should be aware of (e.g. epilepsy, asthma, diabetes, etc.)
Emergency contact details
To be completed by parent/carer
Please insert the information below to indicate the person(s) who should be contacted in case of an incident/accident:
Contact name (e.g. parent/carer):
Emergency contact number:
By returning this completed form, I agree to my son/daughter/child in my care taking part in the activities of the club.
I understand that I will be kept informed of these activities – for example timing and transport details.
I understand that in the event of any injury or illness all reasonable steps will be taken to contact me, and to deal with that injury/illness appropriately.
Name of parent/carer:
Signature of parent/carer: Date:
BLACKWELL MINERS WELFARE FOOTBALL CLUB
We are very pleased to welcome you to Blackwell Miners Welfare Football Club
To ensure that we have the correct contact details for you, please insert the information requested below and return this form to The Club Secretary. If you are under 16 please also ask your parents or guardian to sign this form before it is returned.
We will also use this information to ensure that you are kept informed about club events.
Personal details
Name:
Address:
Postcode:
Home telephone number:
Mobile: email:
Date of birth: Gender: Male ¨ Female ¨
Sports equity monitoring
Whilst it is not compulsory that this section is completed the following paragraph explains why it is important.
Sport can and does play a major role in promoting the inclusion of all groups in society. However, inequalities have traditionally existed within sport, particularly in relation to gender, race and disability. Sport England is committed to promoting and developing sports equity, which is about fairness in sport, equality of access, recognising inequalities and taking steps to address them. By monitoring the profile of young people in sports clubs, national governing bodies of sport and Sport England can identify any issues relating to under-representation of different groups and can together develop strategies to ensure that all young people have the opportunity in the future to develop and progress in sport.
Ethnicity
In order to help the club monitor its membership can you please tick one of the following boxes to identify your ethnic group / origin:
Choose one section from A to E and then tick the appropriate box.
AWhite
0 British 0 Irish
0 Any other white background (please specify):
BMixed
0 White & Black Caribbean0 White & Black African
0 White & Asian
0 Any other mixed background (please specify):
CAsian or Asian British
0 Indian0 Pakistani0 Bangladeshi
0 Any other Asian background (please specify):
DBlack or Black British
0 Caribbean0 African
0 Any other Black background (please specify):
E Chinese or other ethnic group
0 Chinese
0 Any other (please specify):
Disability
The Disability Discrimination Act 1995 defines a disabled person as anyone with ‘a physical or mental impairment, which has a substantial and long-term adverse effect on his or her ability to carry out normal day-to-day activities’.
Do you consider yourself to have a disability? 0 Yes 0 No
If yes, what is the nature of your disability?
0 Visual impairment
0 Hearing impairment
0 Physical disability
0 Learning disability
0 Multiple disability
0 Other(please specify):
Sporting information
Have you played FOOTBALL before?0 Yes 0 No
If yes, where have you played the sport: (please indicate below)
0 Primary school
0 Secondary school
0 Local authority coaching session (s)
0 Club
0 County
0 Other (please specify):
Medical information
Please detail below any important medical information that our coaches/junior coordinator should be aware of (e.g. epilepsy, asthma, diabetes, etc.)
Emergency contact details
To be completed by parent/carer
Please insert the information below to indicate the person(s) who should be contacted in case of an incident/accident:
Contact name (e.g. parent/carer):
Emergency contact number:
By returning this completed form, I agree to my son/daughter/child in my care taking part in the activities of the club.
I understand that I will be kept informed of these activities – for example timing and transport details.
I understand that in the event of any injury or illness all reasonable steps will be taken to contact me, and to deal with that injury/illness appropriately.
Name of parent/carer:
Signature of parent/carer: Date:
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